OSHKOSH - It's been nearly a year since a patient at the state's mental health "safety net" hospital took a bad fall and died, setting off a series of investigations into dangerous conditions at the facility.

Despite some ongoing issues, the facility got a passing report card last month from federal officials.

Officials at the Winnebago Mental Health Institute — the only facility in the state required to take anyone having a mental health crisis — have promised ongoing improvements, including additional staff. But while they've brought on temporary and contracted staff, their shortage of full-time employees has gotten worse.

The Wisconsin Department of Health Services, which runs the facility, reported at least 59 full-time staff vacancies as of Sept. 10. That's a vacancy rate of about 10 percent. It includes six open psychiatrist positions and 14 psychiatric care technicians.

The department reported 18 more vacancies than it did in July, the last time USA TODAY NETWORK-Wisconsin requested figures. The facility houses about 180 children and adults from all over the state who are in mental health crisis or court-ordered treatment.

An April report found heavy reliance on overtime caused staff to quit and increased risk of harm to patients. Some employees reported working 16-hour shifts back to back.

Federal inspectors got involved at Winnebago after a 58-year-old Racine County man fell last October. After hitting his head around 10 a.m. and becoming unresponsive, staff didn't send the patient to an emergency room until after midnight, inspectors found.

At one point after his fall, the patient urinated and staff told inspectors it wasn't cleaned up because of limited staffing. The doctor tasked with checking on the patient was a new hire and wasn't being properly supervised or reviewed. Prosecutors declined to press charges. The Winnebago County Coroner's Office still has not determined the patient's cause of death.

The facility self-reported the death to state health officials and to the Centers for Medicare & Medicaid Services, a CMS spokeswoman said.

Inspectors then found Winnebago did not have enough staff to keep patients safe or honor their rights — among other violations. The CMS notified the facility it was out of compliance with standards required for receiving federal funds. The CMS gave the facility opportunities to improve but found dangerous conditions again in February and June.

In the June inspection, most of the patients inspectors reviewed did not have customized treatment plans, and staff were failing to evaluate results of their treatment. Inspectors found patients "roaming" and "idly sitting around" because there weren't enough activities and therapy opportunities, especially on weekends.

A spokeswoman for the state Department of Health Services said the facility brought on temporary staff to boost coverage on nights and weekends. It also started providing more group therapy sessions, and offered training for staff to better document treatment plans.

Inspectors visited the facility again in August and told the facility in September it is back in compliance.

The DHS spokeswoman said the department is still working to recruit full-time staff.